Provider Demographics
NPI:1053577510
Name:JERRY D WARTHMAN, O.D., LLC
Entity type:Organization
Organization Name:JERRY D WARTHMAN, O.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:WARTHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-644-0060
Mailing Address - Street 1:1923 W 53RD ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46013-1109
Mailing Address - Country:US
Mailing Address - Phone:765-644-0060
Mailing Address - Fax:765-644-0076
Practice Address - Street 1:1923 W 53RD ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-1109
Practice Address - Country:US
Practice Address - Phone:765-644-0060
Practice Address - Fax:765-644-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002286A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100331000BMedicaid
IN200953040Medicaid
IN100331000BMedicaid
1246320001Medicare NSC
306120Medicare PIN